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ORIGINAL RESEARCH

A Qualitative Study Exploring Facilitators and Barriers to Implementing Smoke-free Homes in Georgia
Ana Dekanosidze1,2,ID, ​Veriko Gegenava2, Levan Liluashvili2,​​ Lela Sturua2,ID, Michelle C. Kegler3,ID, 
Levan Baramidze4, Nino Kiladze1,ID, Carla J. Berg5,ID
Received: 24 Oct 2024; Accepted: 5 Dec 2024; Available online: 9 Dec 2024
References
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ABSTRACT
Background: Georgia is a middle-income country with high male smoking rates and recently implemented public smoke-free policies. In contexts like Georgia, smoke-free homes (SFHs) can play crucial roles in reducing secondhand smoke exposure and use prevalence.

Objectives: This study examined barriers and facilitators to SFHs among Georgian adults.

Methods: In February-March 2024, focus groups were conducted separately with smoking and nonsmoking adults in 2 rural communities (n=25; Mage=42.92, 52.0% female, 48.0% married). Data were examined using thematic analysis.

Results: Smoking participants (n=13) were primarily (84.6%) male; nonsmoking participants (n=12) were primarily (91.7%) female. Despite 72.2% reporting complete SFH restrictions, several exceptions and implementation challenges were noted. Smoking was commonly allowed for certain people (e.g., guests) or rooms/spaces (e.g., kitchen, balcony). Salient challenges included prevalent male smoking, difficulty changing behavior (smoking in general and smoking in the home), noncompliance, and accommodating guests, older extended family members, and important traditions and celebrations. However, important SFH motives were the health of non-smokers, particularly children, and serving as good role models for children.

Conclusions: Effective SFH interventions for Georgian households must address specific characteristics (e.g., high male smoking rates, hospitality, accommodating important traditions) and may serve as models for other countries with similar characteristics.

Keywords: Secondhand smoke exposure; smoke-free homes; tobacco.


DOI: 10.52340/GBMN.2024.01.01.89
INTRODUCTION

The tobacco epidemic has increased in low- and middle-income countries (LMICs), where >80% of the world's smokers reside.1 Tobacco control is a global health priority, given the related morbidity, mortality, and economic burdens.1 One important component is secondhand smoke exposure (SHSe), which causes ~600,000 premature deaths annually worldwide and disproportionately impacts women.2 A priority tobacco control measure is implementing smoke-free policies, which reduce SHSe and promote cessation.1 Unfortunately, only 25% of the world's population resides in countries with comprehensive smoke-free laws.1

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Even comprehensive legislation typically does not cover private settings like homes.2 The home is a primary source of SHSe in countries with and without national smoke-free laws.2 A 2017 study of 28 European Union countries found that home-based SHSe contributed to 24,000 deaths (0.46% of total deaths); further, South-Eastern European Union countries (e.g., Romania, Hungary) showed the most tremendous burden.3 Because evidence indicates that smoke-free legislation promotes private smoke-free settings,4-8 promoting smoke-free homes (SFHs) may be particularly effective when capitalizing on a window of opportunity presented by recently implemented public smoke-free policies.

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Interventions promoting SFHs can reduce SHSe.9-12 Yet, relatively few studies have evaluated SFH programs outside the context of protecting young children from SHSe13,14 or explicitly focused on LMICs.15 Georgia is one middle-income country (a former Soviet Republic) that has a high male tobacco use prevalence (49.5%) but a lower rate among women (8.5%).16 Georgia ratified the WHO FCTC in 2006 and 2017-2018 and adopted and implemented progressive tobacco control legislation, including a comprehensive public smoke-free law. However, over half of Georgian adults report past-month SHSe and allow smoking in the home.17

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Many studies have identified facilitators and barriers to creating an SFH. While facilitators of establishing SFHs include perceived harm of SHSe, especially to children's health, desire for cleaner homes, avoiding the smell of smoke, community norms for smoke-free places, and influences of non-smokers,17-20 barriers include denial or poor knowledge of SHSe risk, misconceptions regarding SHSe reduction strategies, inconvenience of going outside, weather, and social gatherings.13,17-22 There may be unique considerations for SFHs in Georgia stemming from sociopolitical and/or cultural differences.23 Thus, it is important to identify barriers and facilitators similar to those in other countries (e.g., US, Australia)13,17-22 and those unique to Georgia. Prior research has shown that common SFH motives among Georgian adults included preventing the smell and protecting children and non-smokers. In contrast, common barriers were smokers' resistance and misconceptions about SHSe reduction strategies (e.g., opening windows and limiting smoking areas).17,24

While prior studies provide insights to guide Georgia-relevant intervention research, surveys precluded more in-depth discussions of facilitators and barriers and may have lacked assessment of crucial factors.17 For example, given Georgia's sociopolitical history and the prominence of family in the Georgian culture,25 intervention messages appealing to ideals of community, hospitality, and/or protecting youth warrant further exploration.

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This study aimed to augment the current literature by qualitatively assessing the process, barriers, and facilitators to creating SFHs among smoking and nonsmoking adults in Georgia. The ultimate goal was to develop culturally relevant interventions for Georgia. The focus on Georgia is particularly timely given the recent implementation of Georgia's national smoke-free policy. It also helps inform SFH interventions for other LMICs with high male smoking prevalence.

METHODS

Procedures and participants

The Institutional Review Board of George Washington University approved this study. In January – February 2024, we conducted four focus groups in two rural communities in Georgia, with two focus groups among those reporting current cigarette smoking and two among those reporting no cigarette smoking. Focus groups are well-suited to exploring phenomena not previously well explored and are thus appropriate, given the lack of prior research on SFH restrictions in Georgia.26,27

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Local public health centers and community leaders recruited eligible individuals (i.e., either reporting past-month smoking or reporting non-smoking status but living with someone who smokes and is Georgian-speaking). Participants were scheduled for a focus group based on their smoking status. Focus group discussions were conducted in conference rooms at the local public health center and administrative facilities in the two communities and followed the consolidated criteria for reporting qualitative research (COREQ).28 Before the discussion, participants consented and completed a brief survey. Two research team members with experience in qualitative methodology moderated the focus groups, lasting ~90-120 minutes. Sessions were audio-recorded. Participants were compensated with small gifts (e.g., t-shirts, notebooks).

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After the four focus groups, the research team determined that saturation had been reached (i.e., no new themes emerged), and recruitment was discontinued.29 The focus groups had a range of sample sizes (n=6 to 9; median=6.25; overall, 39 participants).

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Assessments

The research team developed the focus group discussion guide based on prior research and pilot tested through mock discussions among staff members.19,30,31 It explored perceptions of SHSe (e.g., "In your community, how big of a health issue is SHSe inside the home?"), personal practices regarding smoking in homes (e.g., "What rules do you have about smoking in your home? Who in your household smokes? Are certain people allowed to smoke in your home? What specific times/instances is smoking allowed?"). Moreover, communication among household members regarding smoking in the home (e.g., "Are there ever any discussions about smoking in your home with household members?"). Participants were also asked to provide insights regarding strategies to promote SFHs.

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Participants completed a brief questionnaire assessing age, sex, education level, monthly income, type of housing, relationship status, household members who currently smoke, children under age 18 in the home, rules regarding smoking in the home or in the car, and cigarette use.32

 

Data analysis​

Research assistants transcribed and translated focus group recordings into English. The research team used an iterative process to develop a master coding structure. Using qualitative analysis software (Dedoose), transcripts were independently reviewed by two researchers trained in qualitative analyses who used inductive analysis to generate preliminary codes. Primary (i.e., major topics) and secondary codes (i.e., recurrent themes within topics) were defined in a codebook. Two of the four focus groups were dual-coded; after each of the dual-coded focus groups, the coders met to determine inter-rater reliability (>0.90) and resolve any discrepancies. Then, the final two focus groups were coded. Themes were then identified and agreed upon, and representative quotes were selected. Descriptive and bivariate analyses were used to characterize the sample overall and by smoking status.

RESULTS

Participant characteristics

The sample was, on average, 42.92 years old (SD=12.03), 52.0% female, and 48.0% married (Tab.1).


TABLE 1. Sociodemographic and tobacco use-related characteristics among adult participants in Georgia (N=25), overall and by smoking status
image.png
Explanations: *All n (%) except age (mean, SD). P-values from t-tests and ANOVA for continuous variables (i.e., age) and Chi-square tests for categorical variables. #n=2 reported other. ^n=2 do not own a vehicle. ╪ Scale of 1=not at all to 4=very.

Qualitative findings

Shown in Supplementary Table 2, major topics included the impact of SHSe in Georgia, the nature of SFH rules, how household members interact regarding SHSe and SFH rules, motives for having an SFH, challenges to implementing SFH rules, and strategies to promote SFHs.

 

Impact of SHSe in Georgia

Most participants emphasized that SHSe in Georgia was a big problem. One nonsmoking female said, "This is quite serious, especially if children are in the family. Under no circumstances should you bring it home." Similarly, one male who smoked said, "I think it is a problem for everyone. The problem is how it harms himself, and others do not like it to inhale the smoke."

 

The nature of SFH rules

Household members who smoke were often the male head of the household and extended family members. Various rules were reported. Highlighting the contrast between those with and without restrictions, one male who smoked reported, "All my friends smoke, and we smoke at home," while another said, "It is strictly forbidden at our place. Whoever comes knows it, any guest who may come. If it is summer, then friends and smokers prefer to sit outside. In winter, they go out to smoke. It is crystal clear." Similarly, one nonsmoking female said, "No one smokes at my place. All guests go outside."

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Various exceptions were reported. Allowing certain people, like guests or older extended family members, was frequently reported. One male who smoked said, "You cannot tell a guest. We can tell each other if it is a friend, but you cannot tell a stranger not to smoke at home." Another said, "A guest needs to know the rules in the house. Without warning, he should get up and go outside to smoke. When I am a guest, I go out to smoke."

Similarly, a nonsmoking female indicated, "It is awkward asking guests to go out to smoke. Sometimes, they smoke inside without asking permission. If he asks, we tell him to go out." Almost all participants noted that smoking in the home when children were present was prohibited.

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Another prominent theme regarding partial restrictions was limiting smoking to specific rooms or spaces. Several noted that smoking was allowed – or occurred – in the kitchen, living room, and other common areas. One male who smoked said, "If the kitchen is a gathering place, then they can smoke there, in places where people gather." Many reported that those who smoked did so near windows or on the balcony to help with ventilation, although this did not always prevent SHSe. One nonsmoking female said, "We have guests smoking by the window. My husband also smokes by the window. Most of it goes outside, but the smoke also comes inside." Another said, "My husband smokes on the balcony but is so close that half the smoke gets inside." Several also noted that, if homes did have restrictions, smoking often occurred in the yard or garage.

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Another common theme was exceptions related to bad weather (i.e., cold). One male who smoked said, "Very rarely, when it is too cold, I may smoke in the kitchen. I open the window when everybody is asleep." A nonsmoking female said, "When the weather is nice, [husband] goes out. When it is cold, he gets lazy."

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Interactions regarding SHSe or creating an SFH

Participants reported various experiences regarding how household members communicate about smoking and SHSe in the home. Many indicated that people often disregarded smoke-free rules; one male who smoked said, "It is useless with Georgians. They still smoke inside, and an uncomfortable smell stays when they leave." Non-smokers frequently commented on the challenges of discussing this with males in the household or with guests; one nonsmoking female said, "I want to talk about it, but it might cause trouble in the family, so I refrain." However, many commented that their current rules resulted from ongoing discussions with household members.

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Motives for creating an SFH

The most significant amount of discussion regarding motives for creating an SFH focused on the health of non-smokers, particularly children. One male who smoked noted, "It is a responsibility to our children and the elderly. I have an old mom, children, and wife, and I know it is harmful. I think it is mainly for family members. For me, that is the reason, not to harm the health of my children and family members." Many commented on the importance of setting a good example for their children. One male who smoked said, "In my family, I have children: my boy is 14. I tell him: 'Do not smoke, do it this way, play that way.' Moreover, he asks me to be an example, not to smoke."

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Another salient theme was keeping the house clean and free of the smell of smoke. One male who smoked commented, "I am a smoker, but I do not like the unpleasant smell of places where people smoke. It is full of smell, all the more impressive for a non-smoker. Moreover, ashtrays full of cigarette butts are disgusting."

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Challenges to implementing an SFH

A critical set of challenges to implementing an SFH was related to general difficulties in changing behavior – including quitting smoking in general and quitting smoking in the home. One male who smoked noted, "Almost every day: why don't you quit, it is enough, you smoke too much, etc. I am used to it. I am trying, but so far, no success." Another said, "In our homes, families, wherever I go, I always go out to smoke. We all do that way. We could not stop smoking, though." Another commonly reported theme was that household members might/do ignore the rules; one nonsmoking female said, "This is noticeable even in our building. When we enter our room next to those who smoke, there are bans, but they still smoke." Finally, some commented on how having SFHs might impact Georgian traditions; one male who smoked said, "Georgian traditional feast does not go well with leaving-returning, smoking, getting inside, so that toasts are missed."

DISCUSSIONS

Findings indicate that despite increases in SFHs in Georgia in recent years – alongside the implementation of progressive smoke-free public policies – ongoing challenges must be addressed to optimize the window of opportunity afforded by recent tobacco control legislation. This legislation may accelerate shifts in social norms, which could promote greater confidence among individuals to implement and enforce their voluntary policies in private spaces,33 which could, in turn, catalyze the effects of the national legislation.33,34 This is particularly relevant, given that smoking among Georgian adults most frequently occurs in homes and cars,35 where most SHSe occurs among children and non-smoking adults.36
 

Findings regarding facilitators and barriers to implementing an SFH are largely consistent with research exploring similar topics using qualitative approaches in other countries13,19,20,30,37 and using survey-based methods in Georgia.17,38 While the most salient motive for creating an SFH was to protect non-smokers, particularly children, notable challenges were the difficulties with changing behavior – both smoking in general and smoking in the home – as well as noncompliance with SFH rules. However, additional motives and challenges were more specific to the Georgian culture. For example, in Georgia, there is a central focus on family. Over half of the Georgian households are multigenerational, as in many countries in this region.39,40 Thus, children in the home may also be grandchildren, so managing the multigenerational aspect of smoking is important. There were also challenges related to hospitality and traditions, specifically that it was deemed inappropriate to ask guests to smoke outside and that SFHs could disrupt traditional Georgian feasts – or 'supras' – which are a significant part of Georgian social culture to celebrate specific events (e.g., weddings, birthdays, visitors) and involve long multicourse meals with multiple toasts.
 

Current findings have implications for research and practice. Research to develop interventions to promote SFHs in Georgia should emphasize the impact on non-smokers, particularly children, and engage them in both promoting SFHs and supporting household members who smoke. Additionally, interventions that appeal to men and empower women may enhance men's motivation to protect their families and buy-in to implementing SFH rules and build skills and confidence among women to navigate implementing and enforcing SFH rules effectively. Finally, such interventions must consider accommodating household members and guests who smoke, in general, and in the case of Georgia-relevant contexts, such as multigenerational households or guests or celebrations involving social interaction.


Limitations

Findings from this small sample, which generally involve more rural communities in Georgia, may not generalize to other Georgian adults. Selection bias may have also impacted the generalizability of findings. Additionally, self-reported assessments limit how much we can account for bias. Despite these limitations, findings are important given the limited research on voluntary SFH policies in Georgia and the identification of country-specific barriers that should be addressed.

CONCLUSIONS

Given the high male smoking prevalence in Georgia and the historical impact on SHSe among non-smokers and children, the recent implementation of progressive tobacco control policies marks a pivotal time to accelerate their impact on those who do and do not smoke. Developing effective, culturally relevant interventions to promote SFHs in Georgia is important to this strategy. Findings underscore the promise of current evidence-based interventions that could be adapted to address specific facilitators and challenges relevant to Georgian households. This work may inform SFH interventions in other countries that share characteristics of Georgia (e.g., high male smoking prevalence, family-oriented, recently-implemented smoke-free policies).

AUTHOR AFFILIATION

1 Department of Hygiene and Medical Ecology, Public Health Faculty, Tbilisi State Medical University, Tbilisi, Georgia

2 Department of Hygiene and Medical Ecology, Public Health Faculty, Tbilisi State Medical University, Tbilisi, Georgia

3 Department of Behavioral, Social, and Health Education Sciences, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA

4 Department of Public Health, Management, Policy and Health Economics, Public Health Faculty, Tbilisi State Medical University, Tbilisi, Georgia

4 Department of Prevention and Community Health, Milken Institute School of Public Health; George Washington Cancer Center; George Washington University, Washington, DC, USA

SUPPLEMENTARY MATERIALS

Supplementary Table 1

FUNDING

This work was supported by the US National Cancer Institute (R01CA278229, MPIs: Berg, Kegler) and the National Institute of Environmental Health Sciences/Fogarty International Center (D43ES030927, MPIs: Berg, Caudle, Sturua). Dr. Berg is also supported by other US NIH funding, including National Cancer Institute (R01CA275066, MPIs: Yang, Berg; R21CA261884, MPIs: Berg, Arem), Fogarty International Center (D43TW012456; MPIs: Berg, Paichadze, Petrosyan), and National Institute on Drug Abuse (R01DA054751, MPIs: Berg, Cavazos-Rehg).

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